9 HARBOR VIEW TER - BUILDING INSPECTION (2) �
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�r{p�Sfi�Ef�L� A�PROYED 8Y �1E
.IAISJ3E�JP� PFJIS�A 7P A PEAMIT B�G GRANTED
� CITY OF SALEM
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Is PropeAy Located in B,��g � fE/��°�K ✓/e`�
the Historic District? Yes_NA J ��Ki24��
Is Property Loceted in Y��No_
-` the Conservetlon Area?
BUILDING PERMIT APPLICATION FOR:
Permit to: hed, Pool
(Circle whichever apply) Roof, Reroof, Instatl Siding, Construct Deck, �/_J�
RepaidReplace, Other.�%� ��^� ��'"�'�� '�
PLEASE FlLL OUT LEGIBLY &COMPLETELY TO AVOID DELAYS IN PROCESSING
TO THE INSPECTOR OF BUILDINGS: _
The undersigned hereby applies for a permit to build according to the following
spec'rfications:
Owners i��me i e�S�P��
'J '� �2r{c P B7� 1 '7N'� v�53
Address & Phone 9 �/��� ���— —
Architect's Name I` G . fZ C L L �
Address & Phone
3�i7 �'s��Dt, �; �4LQ,^> N�i,_n_�k �r�� a �lS�
Mechanics Name
�( � �E�2i2ET��� '
1 1 ' i �'.ws � �_� �7/a
Add�ess & PhOne�� �/n0� L�C 5� -H ✓�' � � � ��'` .
L�✓i�l S7 �e
yy�t�g t�e ourpose ot buildl�g? ' .
�Aetedel of building7 �ti� u u� II a dwelling, for how many famitles4
WIII bWlding coMortn to law7
Asbestos7 pV�
c����� �m�U�x N °' �t � D��aS�
Estlmated cost .—�
(c�V " �L/ Ha�e 7mPro°sent
� �• � `S � Signature of pplicant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIP'TION OF WORK TO BE DONE
I 3 � � p �,JC YP�.Sn / � U�—
1 � d 1 /�r�N
�Tc�e� , d'�N�✓ATe �c7c ���1
MAIL PERMIT T0: � e s ��e ��y�J,��/''�A��P
. �ff�"'—r �u �
. _ , , �, �
No. ��%�
APPLICATION FOR
PERMR TO
(0+, 5 J�/�w<� �r ��'d-�� ,c�lLr�C��
LOCATION
�J �J / � �
( / f"C��90 rL, e-n/ /G��,e
PERMIT GRANTED
� y��o�o� ��
A AOV�D
INSPEC _ R OF BUILDINGS
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, CITY OR 3ALEM� MASSAC
H lJ
SE
TTS
PUBLIC PROPERTY DEPARTMENT
120 WASNINGTON STRL�. 9RD FIOOR
SALfM, MASSACMUSETTS 01970
lTANL[Y J. U�py�CZ� JII, T[LFrMON[: 979-7qs_BSpS E7lT. 380
MAYOII FA%: 975-740-9646 -
S8llnl BII��II4�pD�rtmanf
DC�!'jd���-...8� F°0171d
- U►accordance with the provisions of MGL c40 S 54, a condition of your
Building Permit is that che debris resulting from this work shall be disposed
of in a properly licensed solid waste disposal facility as defined by MGL
Chapter III, S 150 A.
The debris will be disposed of in:
(Locadon of Facili ) rL-� s;�_P G �,J�
, ---
Signature of Applicant
�
Date
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ACOR_D_,,, CERTIFiCATE OF LIABILITY INSURANCE ( DATE(MMIODIYY'/Y)
04/03/2006
� aeooucee (g�8) 922-4600 THIS CERTIFICATE IS ISSUED AS A MATTEl2 OF INFORMATION
ARCHER INSUF�ANCE ONLY AND CONFERS NO RIGHTS UPON"i -THE CERTIFICATE
- HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
271 CABOT ST ALTER THE COVERAGE AFFORDED BY THE ROLICIES BELOW.
BEVERLY MA 01915- INSURERSAFFORDINGCOVERAGE ��NAIC#
MSURED INSURER A:PENN—AMERICA
Verrette, Ronald iNsuaeae:LIBERTY MUTUAL
16 Nor£olk Street iNsuReac:
� wsuRER o� - "
Haverhill MA 01630-310 wsuaEae
COVERAGES � �
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE WSURED NAMED ABOVE FOR THE POLICY PERIOO INDICATED:NOTWITHSTANDING ANY
REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAV BE ISSUED OR MAY PERTAIN,
THE INSURANCE AFFORDEO BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.
AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
IINSR AOD'L POUCY EFFECTIVE POLICY EXPIRATION
LTR INSRO -TYPEOFINSURANCE POLICVNUMBER pATE(MMIOD/VY) OATE�MM/OO/VY) 1LIMITS
A GENER4LLIABILITY PAC6464229 �2�22�2006 02�22�2007 EACHOGCURRENCE '�. $ 300�0�0
X COMMERCIALGENERqLLIABILITV OAMAGETORENTED � SO�OOO
PREMISES Ea occurrence $
CLAIMS MADE � OCCUR � � � I '� ME�E%P(Any one persdn) $ S�OOO
PERSONAL&ADV INJURY 8 3OO�OOO
' � � � � GENERALAGGREGATE $ 6OO�OOO
GEN'LAGGREGATELIMITAPPLIESPER: �� PRODUCTS-COMP/OP.AGG $ 300�000
Poucv �Ec°r �oc / / / /
AUTOM001LE LIABILITY � � � � '
COMBINEDSINGLELIM'T $
ANVAUTO ' (Eaaccitlenl)
n��owNeonuros / / / /
BO�ILYINJURY $
SCHEDULEOAUTOS (Perperson) .
HIRE�AUTOS � � � � BODILYINJURV �
�� NON-OWNEDAUTOS (Peraccitlent) ' $
/ � � � PROPERTVDAMAGE �9 '
(Peraccidenl) $
GARAGE LIABILITY "
� AUTOONLY-EAACCI�ENT $
ANYAUTO � � � � OTHERTHAN EAACC $ -
' AUTOONLV: ;AGG 8
E%CESS/IIMeRELLALiABILITY � I I � EACHOCWRRENCE . 5
OCCUR � CLAIMS MADE AGGREGATE ' $
$
DEDUGTIBLE I � � � � - g
RET[NTION $ $
WORKERSCONPENSATIONAN� WCl-31S330828—011 �9�28�2�05 ��3�28�200() ORY�AMITS ' �ER
�I EMPLOYERS'4ABI4TY
ANV PROPRIETOWFARTNEWEXEGUTIVE E.L EAGH ACCIOENT ' $ lOO�OOO
OFFICER�MEMdER EXC W DEU? �
II yes,tles<ribe under � � � � E.L DISEASE-EA EMPLOVEE$ 100�000
SPECIALPROVISIONSbelow E.I.DISEASE-POLICVLIMIT $ SOO�OOO
OTHER / / / / ,
� � � �
� � � �
DESCRIPTION OF GFERATIONSILOCATIONSNEHICLESIE%CLUSIONS A�DED BY EN�ORSEMENTISPECIAL PROVISIONS .
I �
CERTIFICATE HOLDER CANCELLATION
� � � � — SHOULD ANY OF THE ABOVE OESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRAfION DATE THEREOF, '(HE ISSUING INSURER�WI�L EN�EAVOR TO MNIL
?O DAYS WRITTEN NOTICE TO THE CERTIFIGATE HOL�ER NAMEO TO THE LEFT,BUT
C ZTY OF SALEM FAILURE TO DO SD SHALL IMPOSE WO OB4C�ATIO O{t LIA9ILITY OF ANY KIND UPON THE
ATTN:BUILDING INSPECTOR INSURER,ITSAGEryZS,QRREPRESENT/RTIV@S.- /
CITY HALL AUTHORIZEDREPRESENTA VE! , � � •
SALEM MA 01970- � -'"'�
ACORD 25(2001/08) .`�� O ACORD CORPORATION 1968
���.�INS025�Ot08).OS ELECTRONICLASEPFORMS,INC.-(800)327-0545 �� � Pageiot2
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1.�-I-am s�: , •� � �I am a genaai oontractor ond I ���P������:
�e��'.� � �ave naea me�s�o�s D xea oo�u�don
empbyea(mu am/a�put��me} ssoea�me amchea�uee�.t �: {�j xemoaet�
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sn;p am um m emptoyea �ae mb-conaacen nave s. p nemout�
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[Ne�uotke4�aa�y,mwraotx . S. � We ae�cmPp�?a�aod�' � �
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officai bqyne eu�ieo��ea 10.�Electrical�aus os additio�
3.� I�m a homeowmt.domi�11 wotk right ofeiiAoptiqn pdMCZ;" !1.Q PS�bini re�in �addidonr
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r.aqr�ernployorA�rbpro►�lna,vo.kers'eon�pau�Aloabiaw+u�ala�a�pfo�et� ael�.6rRsp�y.�Jo3sla
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AitaeY a eop�d 16e�vorkerr'compenutloa poltq declantloe Ya�e(�Mowlst tie polk�aamber aad e�plratloi date}
Fulme ao saore oovaa�e n reqimed undu Scction 2SA of MGL a 132 cm lead b tLe imposidon ofcr�mal penalties of s
fine up to S 1,500.00 anNo�oao-year�a�weD ar civl pmalaa m the fmm of a STOP WORR ORDER and a 6ne
of up to SZ30.00 s dry agamat 9�e violatoc He advibed that a oopy of thu statemeat may be�udad b tLe OtHce of
Iavati�aons of the DU►far inaurance ooven�e veri&adon.
t b A�aieb� r�4s �nJ a�btet o�1eJone�Now provlJel 6 �nl earecs
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Phone M: ��cY ?�?u �`7/a
O,aldd iut a�l�t !!i�wif wrNt!w tlih�rty te bt rnwplet�l6�edr abw�o,dfel�L
Clt�or To�n: TermkR.loeou N
Issain�Aathork�(drde one):
1.Bard ot Ha1tY 2.HuildlnQ Deputmeot 3.Cky/fow�C1erk 4.Eledrleal Ia:pator !.Plambing Impector
6.Other
Coatzet rmon: Phont M•
Information and Instructions �
....
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,�On�r meie emr�oytp.
�(9ema1 Lsva�cLaPac 1S2 raqnaa aII av111�0�p�!'���� �ofLirq . ' .
po[euffit b fhis�le. ffi s�
�a defiood�"...eiray pasou in�e eavre�f anotM�a a"Y
q�or imphad,oial or vnit0ea' ,
p,n�pfOjur u1 de8ned as"aa mdividoa�,P���'°�°�°����� °i mo�e
in i' �������a� Howey t�e
oitLe� o�����cr ot6rr]eg,�l eo1aY.emPbY�i�P1oY� q..,
teaivaa nn�tea mt mon tba�ra�and wbo raida tLaem.or the o���`'
owncr of s dwcllmi hO°s��1oyi P�m b do mamtenaute.o�nstru�°������b0°��
�house oimother ��abaD not beau�of a�ch emPluYmeat b�damed t�be m emPbya�
ba an tLe�abm7d'mt�
MQ.�154.425G(��stata th�t"eve�ddt or loal tlend�t�i�7�wdt6rald Ht bna�a or
raew�al d t Iks�c or Pe��t0°P��bul�m or to�b�0 i�tYe eommo�wnllt t�07
ippuwt wYo W rat Prod�aa�+�aWaea deomPllasa w�NY tYe W�naae eavua�e nQ�»
nddidonally,l�3.chaP�is�4����teitha the oommnvra�mr anr otia po�dal mb�v� �
eo0a in6��y contc�ct Sot�P�ofpubNc vwd�mti1 acceptablo evidence uf eomPNaou vri�the msoraae
rptnaemean Of thi�chaPoe�Lavebas pram6ed b�a oa�Irudoi.adLot4Y•" • -
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�� . a�ation aod.if
Please fiU,oYt the wotketf'comp�s��°OmPk�'•bY��0 b0ua�at�P�b Y'o� �
neoeasa�Y.�PP�Y�s)name{al add�st(a)u�P��sa�with tLeir ceRi&aBd�)of
in�ur�ce; Limited I.iab�itY ComP�(�°�Limioed Liabi'ht'Y Patooera�(�w;�m���tue
�be�oi partnae,are not raNirad b ca�'���ti0°�' If w LLC a L1B doa Lave
emPlcYa4 a Po1�Y�r�' Be advisad that thu at6dayR�Y����D�e DeQartmmt ot I�ustrial
paidenti S�am�m�of insasauce cova��e. AI�O by wre t°d�ud date t6e amdavk. 'Ihe a�dsvrt slwuid
��d yp�e city or toarn Ihat�e spptiption fa�e pamit ot licenae's beio�ra4oated.ad the D��
SD9o�Y��a�Y 9�����e law or ifyon m reqa'sad to ob�a wrorken'
���� at the�mbet lls9�1kbw. Self-mw:ed oonopamia aL°nid eater tLe�ir
conopenestio�Po���'��6 DewR�
self in�e��O°� ' a tma
qq or Tow�Ofdda4 . �
Please be s�ue tbat the s�davit ir oomplcu wd priated le�bty. 1Le Dcpuunent Laa Fz'cvidod a space at the botoom
of the af6davit far you�0 6ll out in d►e eveut ihe Of9ce of Imesdgatione haa to contxt Yoa re8a�dm6��PP��
Plcase be siae oo�ia the pamalliceme�a wLich will be used as a refueoce m�mber. In addition.au aPP�
iLat mut sabmit�1tiPk Pecm���P�O°�ia a°y�ven yar,aed only submrt one aPgdavit indicatin8 aarent
� pp��p/�IOD(lf L��Y����JOb SrtE Ad�/��E 7�11Cffit ShD➢1d WIItO�31110Cat�dM 1R (�Y�
oown)"A coPY of4ee a�it t�tbn beaa o��d 9I��b7C!��P a wwn maY be P�wid�to da
appHeant a�pmof dut a valid atBdsvit�on 51a fa 6dare pamitt�licema. A oew af�dav��ltbe 911ed au ach
yea.Where a home owna or dt(zea i�ob�s Haeme ar pamit not rdued,�o my businw ar o�erc�e�veamre
(ia a do;liami�pamit to barn lqva eoc.)aaid Paaon a NOT raloued b comPku t6a a�davit
The O�ee of Invati�tnm would 1�7ce oo th�k yoa m advance fa your coopaation and should yoa bave anY 4ue�o�s,
please do not haifa�e b�ve as a c�ll:
The DePa�e°r�addse�,u�P�aod fxc maiba:
The Commonwealth of Massachnsetts
Department of Indushiai Accidenb
O�a of Inveatt�adoa�
600 Washington Strcet
Boston,MA 02111
TeL#617-727-4900 ext 406 or 1-877-MASSAFE
Faa#617-727-7749
RcviSod s-26-os qrWqr.mass.gov/dia
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